Incorporating Key Updates From GOLD Into the Clinical Management of COPD

AJMC^®: Can you please describe your experience with chronic obstructive pulmonary disease (COPD) and its associated clinical burden?

PANETTIERI: I have 30 years of experience as a pulmonary physician, specializing in patients with severe airflow obstruction [and] especially COPD in its chronic bronchitis and emphysema forms. This extensive experience has allowed me to observe the clinical burden associated with [this disease]. COPD has a significant global impact, ranking among the top 5 causes of death worldwide. This disease is characterized by its progressive and debilitating nature marked by periods of stability followed by exacerbations. Notably, these exacerbations lead to the most severe morbidity and mortality in patients with COPD. While therapeutic options have evolved, they have seen fewer innovations in the past 2 decades compared to [those for] asthma, [with most agents featuring] long-acting bronchodilators and some anti-inflammatories.

AJMC: Rates of COPD underdiagnosis have remained high for more than 2 decades. What do you see as the consequences for the patient in terms of underdiagnosis?

PANETTIERI: Underdiagnosis of COPD presents substantial challenges. In the United States, most COPD cases result from cigarette smoking, but the majority of smokers do not develop COPD. As a result, many individuals may unknowingly suffer from declining lung function until the disease significantly impacts their daily life and quality of life. At this stage, a considerable loss of lung function is often irreversible. Smoking cessation is crucial, but lung regeneration is not possible.

To prevent underdiagnosis, early identification through spirometry and attention to even mild symptoms, particularly in individuals as young as 45 [years of age], are vital. Timely pulmonary function testing can confirm the presence of debilitating lung disease.

AJMC: Why do you think the rates of underdiagnosis of COPD might be so high?

PANETTIERI: COPD often goes undiagnosed due to its insidious nature. Patients gradually adapt to reduced exercise capacity and diminished quality of life, making these changes less noticeable. Patients tend to notice significant declines in lung function rather than the gradual and subtle loss that characterizes COPD. Therefore, it is crucial for health care providers to maintain a high suspicion of underlying COPD, [which enables] them to ask pertinent questions and conduct appropriate tests.

AJMC: What difficulties do clinicians face in accurately diagnosing and staging COPD?

PANETTIERI: Clinicians encounter challenges in accurately diagnosing and staging COPD primarily due to comorbidities. COPD is a systemic condition that can affect various organ systems, such as skeletal muscle. Additionally, because COPD typically emerges later in life, it often coexists with comorbidities like hypertension and cardiovascular disease, which can mimic its symptoms. Consequently, health care providers may concentrate on the most apparent cause of the illness and overlook the possibility of COPD contributing to a systemic condition.

AJMC: What role might access and familiarity with spirometry played in underdiagnosis?

PANETTIERI: Access to and familiarity with spirometry play a significant role in the underdiagnosis of COPD. While [other] pulmonologists [and I] routinely use spirometry in outpatient settings, primary care physicians often lack the necessary equipment and expertise to perform spirometry to the required standards. Consequently, they must refer patients to hospitals or specialized outpatient facilities with the essential instrumentation. This hurdle means that, even if a provider suspects COPD, they may face challenges in ordering the necessary pulmonary function tests, which are not readily available in their offices. Unlike conditions like diabetes, where a simple hemoglobin A_1c test is easily accessible, spirometry presents a unique challenge in both diagnosis and [assessment of] disease severity.

AJMC: Each year, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) issues an annual report offering clinical recommendations for the management of COPD. How relevant to clinical practice are recommendations from this report and other guidelines?

PANETTIERI: Guidelines are crucial for standardizing clinical practice and guiding therapeutic approaches for chronic illnesses like COPD. While the abundance of guidelines can lead to fatigue, especially for primary care physicians, there are strategies to streamline their implementation in health systems, hospitals, or practices. Summarized versions of guidelines offer essential, need-to-know information for providers.

Guidelines are typically a blend of expert opinions and evidence-based therapeutic approaches [that form] the foundation for managing chronic diseases. They serve as guardrails, ensuring a structured approach to care. However, it’s important to remember that each patient is unique, and precision medicine should be the goal, considering individual exposures, heredity, ethnicity, and race. Tailoring therapy to the patient’s specific characteristics is a crucial aspect of care.

AJMC: What are the unmet needs in COPD that were addressed in the GOLD 2023 report?

PANETTIERI: The GOLD 2023 report introduced notable changes to COPD guidelines. It condensed the 4-box plot, simplifying patients into those with and without symptoms and an exacerbating phenotype (A, B, and E categorization).

For patients with the exacerbating phenotype, adding inhaled corticosteroids to maximum bronchodilator therapy (with a long-acting β₂ agonist [LABA] or a long-acting muscarinic antagonist [LAMA]) is crucial. When dealing with patients exhibiting symptoms or those without symptoms but with lower FEV₁ [forced expiratory volume in 1 second] spirometry [results], a combination of [a] LABA and [a] LAMA suffices for management. However, for patients prone to exacerbations, inhaled corticosteroids (ICS) become essential. The triple therapy of LABA, LAMA, and ICS is reserved for patients with the exacerbating phenotype.

AJMC: What role might provider familiarity with recent guidelines play in the underdiagnosis
of COPD?

PANETTIERI: Familiarity with recent guidelines is crucial in preventing underdiagnosis of COPD. These guidelines emphasize early spirometry and lung function testing as a screening tool to identify affected patients. Following these guidelines allows for accurate diagnosis and the assessment of disease severity. With this information, tailored therapy can be provided, benefiting the most severely affected patients and minimizing the risk of unnecessary treatments and their associated adverse effects.

AJMC: Authors of the GOLD 2023 report stressed the importance of early detection of COPD. What strategies might providers employ to identify patients at risk for this disease or for COPD exacerbations?

PANETTIERI: One of the most critical tasks for a health care provider is to identify COPD risk and diagnose the condition. First, inquire about a family history of COPD, as it could indicate a genetic predisposition to the disease. Secondly, if the patient is a current smoker, they are at the highest risk for developing COPD, and this group should be promptly identified. Aggressively promoting smoking cessation is essential to reduce this risk. Additionally, be vigilant about occupational hazards like coal mining or asbestos exposure, especially for patients who also smoke, as these factors can increase the likelihood of COPD development. Identifying specific occupational exposures, recognizing genetic predisposition, and assessing smoking history place individuals in a higher-risk category for COPD. In such cases, spirometry becomes crucial for confirming the diagnosis.

AJMC: In the 2023 report, GOLD authors removed their recommendation for the use of ICS unless it is included in triple therapy. How do you see this change impacting your clinical practice?

PANETTIERI: The removal of the recommendation for ICS in the 2023 GOLD report is a significant change with potential impact on clinical practice. It helps address potential overuse of ICS in COPD, where patients were often at risk for pneumonia and other adverse effects.

Now, the emphasis on restricting ICS use to patients with the exacerbating phenotype [and] those needing oral steroids due to exacerbations, [emergency department (ED)] visits, or hospitalizations is a crucial takeaway. For patients without this exacerbating phenotype, ICS use may not be necessary.

These new guidelines enable a more targeted approach, focusing on patients most likely to benefit from ICS. This includes the exacerbating phenotype and those with high baseline eosinophil levels (above 150 cells/µL, typically over 300 cells/µL), as they are more likely to respond to inhaled corticosteroids. This offers a precision biomarker for guiding ICS use in COPD. Patients requiring health care services like urgent care, [ED] visits, scheduled doctor appointments, or hospitalizations should continue to receive [an] ICS in combination with [a] LABA and [a] LAMA.

AJMC: What are your main takeaways from the 2023 GOLD updates, and how do you see them impacting your clinical practice?

PANETTIERI: The 2023 GOLD updates emphasize precision therapy and early intervention for patients with COPD. Identifying susceptible individuals who are prone to exacerbations or developing COPD is crucial, enabling prompt smoking cessation. The recognition of the exacerbator phenotype allows for the rational use of ICS, long-acting bronchodilators, and antimuscarinic agents.

These updated guidelines align with the precision medicine approach to reduce the burden of COPD in terms of morbidity and mortality. Given that COPD ranks among the top 5 causes of mortality worldwide, these changes are vital for improving patient care.

AJMC: What are the biggest unmet needs in COPD management that you hope to see addressed in future GOLD annual reports?

PANETTIERI: In COPD management, significant progress has been made, but several unmet needs must be addressed in future GOLD annual reports. First, we should move beyond the traditional distinctions of chronic bronchitis and emphysema and acknowledge the existence of various COPD subtypes that are not well described.

Second, we lack sufficient biomarkers apart from peripheral blood eosinophil count to effectively categorize and predict therapeutic responses in patients with COPD. Additionally, the development of unique biomarkers is essential for predicting therapeutic responses and accurately assessing disease progression.

Third, the future of COPD management may entail the use of biologics, which [is] currently not approved for COPD treatment. In the next 5 years, we anticipate the introduction of biologics to reduce morbidity and mortality among COPD patients.

Above all, smoking cessation remains a critical priority, as it is the primary cause of COPD in the US. Identifying distinct endotypes or unique phenotypes that contribute to increased morbidity, mortality, and treatment responses is another essential goal.